FAQ - Contract Standardized Training

Questions About:

Care Coordination

Q. Can a provisional licensed professional give care coordinator approval MH/SA?
A. No

Q. Clarify the organizational structure for the UM/Care Coordinator department.
A. UM and Care Coordination should be housed in separate areas, supervised by separate staff, and contact should be restricted to UM requests and justifications.

Q. Can a psychological nurse be used for care coordination?
A. Yes, if there is documented experience with disability.

Q. Does it take two years of post masters experience to become an LCSW?
A. Yes

Q. Is it ok for the UM to document a participant request and disagreement? With a participant request?
A. Yes, participant requests should be documented along with medical necessity justification or disagreement.

Customer Services

Q. Can we refer questions to Medicaid?

A. Your Contract Monitor at the N.C. Division of Medical Assistance (DMA) is always available for assistance, but all questions should be directed to and through the MCO first.

Q. Can you refer people to Website to get details of the services provided?
A. Yes, but if person does not have access to the Internet, then a written explanation of services must be provided.

Q. Does the list of providers have to be broken down by services?
A. No, as long as provider information and area of specialty is included. Best practice, though, would be to provide as much information as possible, including if providers are specialists in different cultural practices or with an LGBT population, for instance.

Due Process

Q. Who takes lead if both PIHP and the Department are named?
A. PIHP

Q. In due process and legal matters, will LMEs represent themselves or will the Attorney General (AG) represent them?
A. LME represents themselves.

Q. Could PIHP extend the authorization or not?
A. Yes, PIHP can extend the authorization.

Q. If a provider submits a timely service authorization, can it be appealed? Can they still receive the same level of service during the appeal?
A. Yes

IT

Q. How frequently can you get full file eligibility from global?
A. Every 24 hrs.

Q. Does daily mean 5 or 7 days a week?
A. 5 days a week

Q. Can we request a full file global?
A. Yes, as needed.

Q. When e-mailing personal history information with phi is security required?
A. Yes

NC innovations 1/26/12

Q. Who is responsible for completing the evaluation?
A. The care Coordinator.

Provider Network

Q. In the application process, how many times can a provider apply if the provider made mistakes on his/her application?
A. Unlimited, although they do have to wait between applications.

Q. If denied, how much time must go by before a provider can reapply?
A. Unlimited

Q. If a provider does not serve anyone in 90 days, do they remain provisional?
A. No, would have to reapply.

Q. Does each individual contract have to be approved by the Secretary of DHHS?
A. No, the contract template has been approved.

Q. What is the definition of a new provider?
A. A new provider is anyone new to the network who has not previously been enrolled to provide services.

Q. If a company in the network already, do they need to be re-credentialed?
A. No.

Q. How do you submit provider information to DMA Provider Services?
A. A template is forthcoming.

Q. Can the out-of-network ED come back to you for more fees?
A. Not beyond the posted fee schedule.

Q. If a facility loses CMS certification, can they receive any other payment?
A. No

Q. If ED and a physician’s group bills separately, does that physician group have to be credentialed?
A. Yes, will have to be credentialed and enrolled if there is a psychiatrist.

Q. Does the NC DMA also check to see if the physician group is in good standing with federal agencies?
A. No, that is the responsibility of MCO.

Q. Does the DMA check the list you send them to see if the physician group is in good standing?
A. Yes, it will be on the template to be sent.

Q. Is there a particular way, or best way, to check good standing?
A. The best way is to contact your contract manager who will notify the appropriate personnel.

Q. Are investigative reports on fraud and abuse confidential?
A. They are not confidential once the investigation is finished. They are confidential when the investigation is ongoing.

Q. Is it possible to create an integrated contract?
A. No

Q. Are reports on fraud sent to program integrity kept confidential or are they public record?
A. They are public record once the investigation is finished. They are confidential when the investigation is ongoing.

Q. If an application for provider service is posted on the web after the end of enrollment period, do we have to accept the application?
A. If it is before the first date of operations, yes. The network doesn’t close until first day of operations.

Q. Is there an FEM on monitoring contract?
A. There is no FEM on monitoring contract.

Q. Can a recipient or a provider appeal a denial of payment?
A. Recipients can appeal denial of authorization; providers can appeal denial of payment.

QM/UM

Q. Is a psychological nurse required to approve an MH/SA review?
A. The minimum qualification required for an MH/SA review is an RN with at least two years of experience in the disability area.

Q. What is the definition of a psychological nurse?
A. A psychological nurse is an RN with at least two years of experience in the specific disability area.

Q. Who can sign-off on the level of care tool?
A. A licensed psychologist can sign-off on the level of care tool.

Q. How does the firewall between UM and Care Coordination work?
A. UM and Care Coordination should be housed in separate areas, supervised by separate staff, and contact should be restricted to UM requests and justifications.

Quality Management

Q. Will the measures be recorded when you are an MCO?
A. Yes

Q. What differences are there between HEDIS and URACI?
A. URAC and HEDIS should match.

Q. Are MCOs going to have to do annual consumer surveys as well as DMH surveys?
A. Yes in the short term; there are State discussions about a long-term simplification.

Q. When is the consumer survey sent out at the state level?
A. The annual consumer survey is sent out in the fall. The DMH survey in sent out in the spring to stagger survey delivery.

Q. Why have two surveys?
A. Currently, we are reporting to several different funding sources about several different populations, not just Medicaid.

Program Integrity

Q. If you find fraud, do you report it to licensing board?

A. We do report licensed and provisionally licensed professionals, and mental health group practices to local professional boards whenever there is fraud and/or abuse by the provider.

Q. If there is a complaint against a provider, and they ask about it , what can you say?

A. We do not confirm nor deny that we have received a complaint. All complaints are confidential until the investigation is complete.

Q. When in the process does it become unconfidential?

A. At the point that the investigation has ended or the case has been closed

Q. What is the time frame between complaint and completion?

A. All cases in PI are to be open and closed within 60 days; however several cases extend beyond the 60 day period due to case complexity.

Q. Is the 60 day timeframe for all complaints?

A. Yes, however complaints are prioritized.

Q. Do all complaints have to be investigated?

A. Yes, if the complaint is determined to be a case.

Q. Being that the LME has 30 days can it be changed to 60 days like DMA has?

A. No, not at this time. Timeframe changes maybe considered in the future.

Q. Do we route to DMA or law enforcement?

A. You route all fraud and abuse cases to DMA Program Integrity

Q. How do you handle jurisdiction of location of fraud if more than one county is involved?

A. Counties should not be involved in a potential fraud case unless it crosses LME-MCOs. Both LME-MCOs need to be named in the potential fraud and the case should be forward to DMA Program Integrity for further review.

Q. Is a false claim considered if a provider submits claim of payment for non-eligible patient?

A. We look at claims that were paid. If claim was not paid, there is no loss to the Medicaid program.

Q. Is the fingerprint requirement just for those who have not been in the state for five years?

A. No, there are some steps that the MCOs have to take to ensure High Risk category providers submit to fingerprinting. Consult NC GS 108C for more information related to enrollment and high risk providers.

Q. What about degrees from non-accredited school? Is that acceptable?

A. The standard DMA Program Integrity uses for degrees is based on the degrees accepted by the Office of State Personnel (OSP). OSP has a list of degrees and programs it has authorized.

Q. Do’s MCO have financial obligation to pay for litigation?

A. Yes.

Q. What is collaboration between MCO’s and DMA and MIU?

A. The MCOs should establish a SIU or Program Integrity Committee to address provider fraud, waste, or abuse. The MCO SIU/Program Integrity Committee, DMA-PI, and MIU will have to meet at least quarterly to discuss cases of suspected fraud and / or abuse.